Dr. Abhishek Jain

MBBS, MS (General Surgery)
FAMAS(Italy), FAAOS(Italy)
FICS (GI Surgery), FISCP (Colo Proctology)
Colorectal Surgery,Advance Laparoscopic Surgery,
Abdominal Oncology Surgery, Bariatric & Metabolic Surgery

What is laparoscopic cholecystectomy?

Gallbladder surgery when performed through the small cuts and a camera is called laparoscopic cholecystectomy.Removing the gallbladder is the preferred treatment for the majority of people who have gallstones that cause symptoms. Laparoscopic cholecystectomy requires several small incisions in the abdomen to allow the insertion of surgical instruments and a small video camera. After the initial incisions, the surgeon will use carbon dioxide to inflate the abdominal cavity. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the organs and tissues. The surgeon watches the monitor and performs the operation by manipulating the surgical instruments through separate small incisions.

The gallbladder is identified and carefully dissected free from its attachments under the liver. One of the most important portions of the procedure is the identification of Calot’s Triangle. Calot’s triangle is an anatomic area bounded by the liver, cystic duct, and common hepatic duct. The cystic duct and the cystic artery are identified, clipped with tiny titanium clips and cut. The gallbladder is then separated from the liver bed and removed through one of the small incisions.

What tools are used for laparoscopic cholecystectomy?

A laparoscope is a small, thin tube that is attached to a video camera and placed into your body through a tiny cut. The surgeon can then see the gallbladder on a television screen and do the surgery with tools inserted in three other small cuts made in the right upper part of your abdomen. Only small incisions are required. The video camera then produces a magnified view on a television monitor of the inside of your abdomen allowing a very detailed view. A number of other laparoscopic instruments are typically used. The gallbladder is then removed through one of the small incisions.

Are there any benefits of laparoscopic cholecystectomy compared with open cholecystectomy?

Surgery to remove the gallbladder with a laparoscope does not require that the muscles of your abdomen be cut in the same manner as as they are in open surgery. With laparoscopic cholecystectomy, you may return to work sooner, have less pain after surgery, and have a shorter hospital stay and a shorter recovery time. Although there are more than one incisions, each incision is much smaller than the typical open incision which makes recovery much quicker.

Most laparoscopic cholecystectomy procedures are performed as an outpatient surgery meaning that you go home the same day as the operation and recover in the comfort of your home.

Is there any reason why I wouldn’t be able to have a laparoscopic cholecystectomy?

If you have previously had surgery in the area of your gallbladder, if you tend to bleed a lot or if you have any problem that would make it hard for your doctor to see your gallbladder, an open surgery may be better for you. Your doctor will decide which type of surgery is best for you.

What are the complications of laparoscopic cholecystectomy?

Complications may include bleeding, infection and injury to the duct (tube) that carries bile from your gallbladder to your stomach. Also during laparoscopic cholecystectomy, the intestines or major blood vessels may be injured when the instruments are inserted into the abdomen. All of these complications are rare but still possible when performed by a laparoscopic surgeon.

What other procedures may be required?

If you have stones in the bile duct as well as your gallbladder, you may require removal of both the duct stones and your gallbladder. In some cases it is best to remove the stones in the bile duct before your operation using an endoscope. If you look at the image to the right, you can see that the stomach and intestines provide a route to get directly to the bile tubes without making cuts on the wall of the abdomen.
The procedure is called an endoscopic retrograde cholangiopancreatography (ERCP) and consists of a scope that is inserted through the mouth, down the digestive tract and then used to instrument the bile tubes from inside the intestines. If you have ERCP, your gallbladder may be removed at a later date or during the same hospitalization. Often, a cutting instrument is inserted through the endoscope, and the entrance of the bile duct is enlarged so the stone can pass through it. The same procedure may be used to remove a stone from a blocked pancreatic duct.

Are there long term effects after gallbladder removal?

Your liver will continue to produce enough bile to digest a normal diet after you have surgery. Please remember the liver produces over one liter of bile a day therefore it is unlikely that the small amount that was stored by the gallbladder will play a noticeable difference in digestion. You may notice you’re having more bowel movements than usual and that their consistency is less solid. These symptoms usually lessen over time. It is normal to have a self-limited change in digestive habits that is unrelated to your type of operation and will improve over time. Some patients however find that diarrhea remains a problem, and a ‘heart-healthy’ diet or one that is low in rich, fatty foods will usually alleviate the problem.

Appendectomy

Definition

Appendectomy is the surgical removal of the appendix. The appendix is a worm-shaped hollow pouch attached to the cecum, the beginning of the large intestine.

Purpose

Appendectomies are performed to treat appendicitis, an inflamed and infected appendix.

Description

After the patient is anesthetized, the surgeon can remove the appendix either by using the traditional open procedure (in which a 2–3 in [5–7.6 cm] incision is made in the abdomen) or via laparoscopy (in which four 1-in [2.5-cm] incisions are made in the abdomen).

Traditional open appendectomy

When the surgeon uses the open approach, he makes an incision in the lower right section of the abdomen. Most incisions are less than 3 in (7.6 cm) in length. The surgeon then identifies all of the organs in the abdomen and examines them for other disease or abnormalities. The appendix is located and brought up into the wounds. The surgeon separates the appendix from all the surrounding tissue and its attachment to the cecum, and then removes it. The site where the appendix was previously attached, the cecum, is closed and returned to the abdomen. The muscle layers and then the skin are sewn together.

Laparoscopic appendectomy

When the surgeon performs a laparoscopic appendectomy, four incisions, each about 1 in (2.5 cm) in length, are made. One incision is near the umbilicus, or navel, and one is between the umbilicus and the pubis. Two other incisions are smaller and are on the right side of the lower abdomen. The surgeon then passes a camera and special instruments through these incisions. With the aid of this equipment, the surgeon visually examines the abdominal organs and identifies the appendix.

The appendix is then freed from all of its attachments and removed. The place where the appendix was formerly attached, the cecum, is stitched. The appendix is removed through one of the incisions. The instruments are removed and then all of the incisions are closed.

Studies and opinions about the relative advantages and disadvantages of each method are divided. A skilled surgeon can perform either one of these procedures in less than one hour. However, laparoscopic appendectomy (LA) always takes longer than traditional appendectomy (TA). The increased time required to do a LA the greater the patient’s exposure to anesthetics, which increases the risk of complications.

The increased time requirement also increases the fees charged by the hospital for operating room time and by the anesthesiologist. Since LA also requires specialized equipment, the fees for its use also increase the hospital charges. Patients with either operation have similar pain medication needs, begin eating diets at comparable times, and stay in the hospital equivalent amounts of time. LA is of special benefit in women in whom the diagnosis is difficult and gynecological disease (such as endometriosis, pelvic inflammatory disease, ruptured ovarian follicles, ruptured ovarian cysts, and tubal pregnancies) may be the source of pain and not appendicitis. If LA is done in these patients, the pelvic organs can be more thoroughly examined and a definitive diagnosis made prior to removal of the appendix. Most surgeons select either TA or LA based on the individual needs and circumstances of the patient.

Insurance plans do cover the costs of appendectomy. Fees are charged independently by the hospital and the physicians. Hospital charges include fees for operating and recovery room use, diagnostic and laboratory testing, as well as the normal hospital room charges. Surgical fees vary from region to region and range between $250–750. The anesthesiologist’s fee depends on the health of the patient and the length of the operation.

Preparation

Once the diagnosis of appendicitis is made and the decision has been made to perform an appendectomy, the patient undergoes the standard preparation for an operation. This usually takes only one to two hours and includes signing the operative consents, patient identification procedures, evaluation by the anesthesiologist, and moving the patient to the operating area of the hospital. Occasionally, if the patient has been ill for a prolonged period of time or has had protracted vomiting, a delay of few to several hours may be necessary to give the patient fluids and antibiotics .

Aftercare

Recovery from an appendectomy is similar to other operations. Patients are allowed to eat when the stomach and intestines begin to function again. Usually the first meal is a clear liquid diet—broth, juice, soda pop, and gelatin. If patients tolerate this meal, the next meal usually is a regular diet. Patients are asked to walk and resume their normal physical activities as soon as possible. If TA was done, work and physical education classes may be restricted for a full three weeks after the operation. If a LA was done, most patients are able to return to work and strenuous activity within one to three weeks after the operation.

Risks

Certain risks are present when any operation is performed under general anesthesia and the abdominal cavity is opened. Pneumonia and collapse of the small airways (atelectasis) often occurs. Patients who smoke are at a greater risk for developing these complications. Thrombophlebitis, or inflammation of the veins, is rare but can occur if the patient requires prolonged bed rest. Bleeding can occur but rarely is a blood transfusion required. Adhesions (abnormal connections to abdominal organs by thin fibrous tissue) are a known complication of any abdominal surgery such as appendectomy. These adhesions can lead to intestinal obstruction that prevents the normal flow of intestinal contents. Hernia is a complication of any incision. However, they are rarely seen after appendectomy because the abdominal wall is very strong in the area of the standard appendectomy incision.

The overall complication rate of appendectomy depends upon the status of the appendix at the time it is removed. If the appendix has not ruptured, the complication rate is only about 3%. However, if the appendix has ruptured, the complication rate rises to almost 59%. Wound infections do occur and are more common if the appendicitis was severe, far advanced, or ruptured. An abscess may also form in the abdomen as a complication of appendicitis.

Occasionally, an appendix will rupture prior to its removal, spilling its contents into the abdominal cavity. Peritonitis or a generalized infection in the abdomen will occur. Treatment of peritonitis as a result of a ruptured appendix includes removal of what remains of the appendix, insertion of drains (rubber tubes that promote the flow of infection inside the abdomen to outside of the body), and antibiotics. Fistula formation (an abnormal connection between the cecum and the skin) rarely occurs. It is only seen if the appendix has a broad attachment to the cecum and the appendicitis is far advanced, causing destruction of the cecum itself.

The complications associated with undiagnosed, misdiagnosised, or delayed diagnosis of appendicitis are very significant. This has led surgeons to perform an appendectomy any time that they feel appendicitis is the diagnosis. Most surgeons feel that in approximately 20% of their patients, a normal appendix will be removed. Rates much lower than this would seem to indicate that the diagnosis of appendicitis was being frequently missed.

About Laparoscopic Hernia Surgery

Laparoscopic hernia surgery is an important part of comprehensive hernia repair. By providing hernia patients the option of laparoscopic hernia surgery, some patients may have a better outcome.Patients who have large ventral hernias, recurrent hernias, bilateral inguinal hernias, and others may be a good candidate for laparoscopic hernia repair. Some patients desire laparoscopic hernia surgery to help minimize their recovery during sports seasons or when there are upcoming athletic competitions.

Laparoscopic Hernia Surgery Repair – Inguinal

A laparoscopic inguinal hernia requires a 1-2cm incision at the belly button, and two smaller punctures below the umbilicus. The belly button incision allows the camera to view the inside of the abdomen and the two smaller punctures are for the operating instruments.

To begin, a balloon is placed from the umbilicus to separate the peritoneum, or the lining of the abdomen, from the overlying muscle. Once this space is created, a camera is placed under the muscle to view the hernia.

The hernia is then pulled back into the abdomen from it’s hole in the muscle. This hole can either be lateral to the blood vessels (indirect inguinal hernia, left below) or towards the middle from the blood vessels (direct inguinal hernia, right below). Regardless, the surgery is the same; once the hole is found, a small mesh is placed under the muscle to reinforce the hernia defect.

Laparoscopic Hernia Surgery Repair Cases – Inguinal

This patient had a noticeable bulge in the left groin. He opted for laparoscopic surgery for treatment. The balloon spacemaker (see above) is placed under the muscle but over the intestines. When the balloon is removed, the hole in the muscle is found. A lightweight mesh is placed over the defect to repair the hernia.

Laparoscopic Hernia Surgery Repair – Ventral/Incisional

Ventral hernias, epigastric hernias, recurrent umbilical hernias, as well as several other, are excellent candidates for laparoscopic hernia repair. Similar to the inguinal hernia, a camera is placed through the muscle into the abdomen along with two smaller punctures for the operating instruments. From there, any scar tissue between the intestine and the hernia is cut allowing complete exposure of the hole.

A hernia mesh is rolled and placed through one of the laparoscopic ports into the abdomen. From there, it is pulled up against the muscle surrounding the hernia with stitches (sutures). Once the mesh is secured in place with about 4 sutures, a special stapling device is used to further fix the mesh to the healthy muscle.

Laparoscopic Ventral/Incisional Hernia Repair Cases

The following two patients had incisional hernias which came back after a prior surgical repair (recurrent incisional hernias). Both were done at large university hospitals and both recurred within months after having their surgery. We treated both patients with laparoscopic surgery after discussions with the patients about their desires and expectations for after the surgery. Some patients will benefit from laparoscopic repair, while some might benefit from an open approach.

1. Laparoscopic repair of recurrent incisional hernia in a 74 year old doctor.

A 74 year old physician had a large pelvic tumor removed which was non cancerous. She developed a hernia 2 years after her surgery and underwent a laparoscopic incisional hernia repair at a large University Hospital in Southern California. Weeks after her surgery, she noticed a recurrent bulge in the lower part of her abdomen.

She presented to California Hernia Specialists for evaluation and treatment. On examination she had a 1-2 inch bulge in the lower abdomen, just above her pubic bone. This recurrent incisional hernia was painful when she exercised and while she was at work. We offered her laparoscopic recurrent incisional hernia repair.

2. Hernia in a 30 year old woman after endometriosis surgery and c-section.

This patient had several surgeries for endometriosis and c-sections. After one of her surgeries she developed pain in the lower abdomen and a bulge. The bulge would get bigger and smaller, and sometimes extend down to the right labia. She had pain with most activities including simple tasks like standing and sitting.

She had a laparoscopic hernia repair previously, but the mesh wasn’t placed low enough to cover the entire hernia defect, or the hole in the muscle. She presented to us for a second opinion and further treatment. Her small intestine was stuck in the hole at the beginning of the surgery and had to be pulled out prior to repairing the defect. A ‘tension free’ repair (see below) was performed.

Tension Free Repair

The term ‘tension free’ hernia repair is commonly used to describe hernia surgery. Hernias are caused by a weakening of the abdominal muscles. Some surgeons choose to sew the muscles back together, thus causing ‘tension’ on the muscles around the hernia. However, the muscles around a hernia are already weak, and over time those muscles tend to pull apart and the hernia can recur, or come back.

Therefore, most hernia specialists today utilize a mesh to help strengthen the muscles. When using a mesh, the muscles themselves are not sewn together (see below). Instead, a mesh is placed over or under the hole in the muscle to prevent anything from pushing through the abdominal wall.

Some patients have heard or read negative information about mesh surgery. However, the unbiased government agency The National Institutes of Health performed a study of whether mesh should or should not be used for hernia surgery. Read the article by clicking on the logo to the right:

Treatment

In most cases, small hernias do not cause symptoms or require treatment. A large hernia may require treatment with medications or surgery.

SurgeryFor people with a large hiatal hernia, repair surgery is sometimes the best option when medications and lifestyle changes have been ineffective. Repair surgery initially involves pulling your stomach down into your abdomen (reduction) and can be combined with other surgeries such as those for gastroesophageal reflux disease (GERD). Based on the cause of your symptoms, your doctor may recommend one of the following additional surgical options after reduction.

Fundoplication. The top part of the stomach is wrapped around the bottom part of the esophagus to strengthen it. The defect in the diaphragm also is closed.

Gastropexy. The stomach is attached to the abdominal wall, if it moves around easily after reduction.

Esophagectomy. The surgeon removes most of your esophagus and attaches your stomach to the remaining portionMost people with hiatal hernia don’t experience any signs or symptoms and won’t need treatment. If you experience signs and symptoms, such as recurrent heartburn and acid reflux, you may require treatment, which can include medications or surgery.

Medications for heartburn

If you experience heartburn and acid reflux, your doctor may recommend medications, such as:

• Antacids that neutralize stomach acid. Over-the-counter antacids, such as Gelusil, Maalox, Mylanta, Rolaids and Tums, may provide quick relief.

• Medications to reduce acid production. Called H-2-receptor blockers, these medications include cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR) and ranitidine (Zantac 75). Stronger versions of these medications are available in prescription form.

• Medications that block acid production and heal the esophagus.Proton pump inhibitors block acid production and allow time for damaged esophageal tissue to heal. Over-the-counter proton pump inhibitors include lansoprazole (Prevacid 24HR) and omeprazole (Prilosec OTC). Stronger versions of these medications are available in prescription form.

Surgery to repair a hiatal hernia

In a small number of cases, a hiatal hernia may require surgery. Surgery is generally reserved for emergency situations and for people who aren’t helped by medications to relieve heartburn and acid reflux. Hiatal hernia repair surgery is often combined with surgery for gastroesophageal reflux disease.

An operation for a hiatal hernia may involve pulling your stomach down into your abdomen and making the opening in your diaphragm smaller, reconstructing a weak esophageal sphincter, or removing the hernia sac. In some cases, this is done using a single incision in your chest wall (thoracotomy) or abdomen (laparotomy). In other cases, your surgeon may insert a tiny camera and special surgical tools through several small incisions in your abdomen. The operation is then performed while your surgeon views images from inside your body that are displayed on a video monitor (laparoscopic surgery).

Acid Reflux and GERD

Acid reflux occurs when stomach acid flows backward into the esophagus. This causes heartburn and other symptoms. Chronic or severe acid reflux is known as gastroesophageal reflux disease (GERD).

Mild or moderate reflux symptoms can often be relieved with diet and lifestyle changes. Over-the-counter and prescription medications can also help with symptom relief.

Medications used to treat GERD include:

• antacids

• H2 blockers

• proton pump inhibitors (PPIs)

Unfortunately, some people aren’t helped by lifestyle changes or medications. Surgery may be an option for those people. Surgery focuses on repairing or replacing the valve at the bottom of the esophagus that normally keeps acid from moving backward from the stomach. This valve is called the lower esophageal sphincter (LES). A weak or damaged LES is what causes GERD.

Mild or moderate reflux symptoms can often be relieved with diet and lifestyle changes. Over-the-counter and prescription medications can also help with symptom relief.

Medications used to treat GERD include:

• antacids

• H2 blockers

• proton pump inhibitors (PPIs)

Unfortunately, some people aren’t helped by lifestyle changes or medications. Surgery may be an option for those people. Surgery focuses on repairing or replacing the valve at the bottom of the esophagus that normally keeps acid from moving backward from the stomach. This valve is called the lower esophageal sphincter (LES). A weak or damaged LES is what causes GERD.

Untreated GERD can develop into a condition called Barrett’s esophagus. This condition increases the risk of esophageal cancer. However, esophageal cancer is rare, even in people with Barrett’s.

WHEN TO CONSIDER SURGERY

Surgery may be recommended if you have serious GERD complications. For example, stomach acid can cause inflammation of the esophagus. This may lead to bleeding or ulcers. Scars from tissue damage can constrict the esophagus and make swallowing difficult.

Surgery for GERD is usually a last resort. Your doctor will first try to manage your symptoms with changes to your diet and lifestyle. This gives relief to most people with the condition. If that does not give you relief, they will try long-term medications. If these steps do not relieve the symptoms, then your doctor will consider surgery. You might also consider surgery to avoid taking long-term medications.

There are several surgical options that may help to relieve GERD symptoms and manage complications. Speak with your doctor for guidance on the best approach to manage your condition.
If your GERD requires surgery, you should be sure and discuss the cost of your surgery with your doctor and the hospital. The costs vary greatly depending on your insurance, the hospital, type of surgery, and other factors.

Surgery For GERD: Pros

1. Helps avoid long-term medications
2. Can help prevent complications such as inflammation of the esophagus
Surgery For GERD: Cons
1. Some surgery options can be costly, depending on your insurance
2. Recovery times differ based on type of surgery, but some require up to 6 weeks of rest before returning to work

FUNDOPLICATION

This is the standard surgical treatment for GERD. It tightens and reinforces the LES. The upper part of the stomach is wrapped around the outside of the lower esophagus to strengthen the sphincter.
Fundoplication can be performed as an open surgery. During an open surgery, the surgeon makes a long incision in your stomach to access the esophagus. It can also be performed as laparoscopic surgery. This type of surgery involves several smaller incisions. Miniaturized instruments are used to make the process less invasive.

The preparation for this surgery is typical of that for any surgical procedure. It may include:

• a clear liquid diet 1-2 days before surgery

• not eating on the day of surgery

• taking a medication to cleanse your bowels the day before surgery

Ask your doctor for specific preparation instructions, as they may differ due to your individual medical history.

This type of surgery generally has a very good rate of long-term success.

TIF (Transoral Incisionless Fundoplication)

This procedure is used when open fundoplication is not appropriate. It creates a barrier between the stomach and the esophagus. The barrier prevents reflux of stomach acid.

This procedure doesn’t require incisions. A device called an EsophyX is inserted through your mouth. It creates several folds at the base of the esophagus. The folds form a new valve. Since it does not require incisions, this can be a good option for people with GERD. If medications do not relieve your GERD, but you do not want more invasive surgery, this may be an option you prefer.

The preparation for this surgery is similar to that of the preparation for fundoplication, but may not require as many steps. Check with your doctor about the right preparations for you.

Stretta Procedure

This procedure is performed with an endoscope. It is usually done as an outpatient procedure. This is a thin, flexible tube that can be threaded into your esophagus. An electrode at the end of the tube heats your esophageal tissue and creates tiny cuts in it. The cuts form scar tissue in the esophagus. This blocks the nerves that respond to refluxed acid. The scar tissue that forms also helps strengthen the surrounding muscles.

This procedure shows effectiveness in relieving or even eliminating the symptoms of GERD. However, this is still a fairly new procedure, so long-term results are unknown.

The preparation for this procedure is much like preparing for fundoplication. But, you should check with your doctor about the correct preparations for you.

This procedure is generally less expensive than fundoplication. It’s important to check with your insurance to be sure it is covered and what the actual cost will be for you.

Bard EndoCinch System

This system also uses an endoscope. Stitches are made to form pleats in the LES. This strengthens the LES. The procedure is not as common as others mentioned above. However, it is another option for you to discuss with your doctor.

This procedure is not covered by all insurance carriers. It is important that you discuss the costs of this, and all, procedures with your insurance carrier, your doctor, and your hospital prior to deciding on the correct procedure for you.

Linx Surgery

This surgery uses a special device called a linx. It’s a ring of tiny magnetic titanium beads. When wrapped around the LES, the linx strengthens the sphincter.

Because the beads are magnetized, they move together to keep the opening between the stomach and esophagus closed. Food can still pass through normally.

Since this is a minimally invasive surgery recovery time is usually considerable shorter than traditional surgery. There is also less pain related to this type of surgery.
This is a relatively new procedure but shows good results for relieving acid reflux disease.

Recovery

Recovery is slightly different for each type of surgery, but depends primarily on whether your surgery is laparoscopic or traditional. While laparoscopic surgery has a quicker recovery time and less pain that traditional, it may not be appropriate for every person with GERD. Your doctor and surgeon will be able to decide which is best for you.

The fundoplication surgery is the most common. The traditional or open surgery requires about a week in the hospital and then about six weeks before you are able to return to work. The laparoscopic fundoplication surgery requires only a few days in the hospital with the patient able to return to work after one week. There is also less pain after this less invasive procedure.

Prior to any surgery for GERD, your doctor will try dietary changes, then medications. If those do not give you relief then, surgery will be suggested.

Laparoscopic Heller myotomy and Dor fundoplication for treatment of achalasia

Achalasia is a degenerative esophageal disease culminating in aperistalsis of the esophageal body and abnormal relaxation of the lower esophageal sphincter. The underlying cause of this T-cell mediated destruction and fibrous replacement of the esophageal myenteric neural plexus is unknown.1–3 Neural function cannot be restored. Therefore, treatment is palliative and directed toward symptom control and preservation of the esophagus as a passive conduit. The treatment principle requires reduction of lower esophageal sphincter pressure while minimizing gastroesophageal reflux. This can be affected laparoscopically by modified Heller myotomy and Dor (partial anterior) fundoplication.

Surgical technique

1. The patient is placed in lithotomy position. The surgeon is positioned between the patient’s legs. The cameraman stands to the patients right and the first assistant to the patient’s left.

2. Using the Hassan technique, a 10-mm port is placed in the mid-line below the xiphoid process, 12 to 23 of the distance to the umbilicus. Carbon dioxide is insufflated to produce a pneumoperitoneum with intraabdominal pressure limited to 15-mm Hg. A 10-mm 30-degree laparoscope is passed through this port and the abdominal cavity visually inspected. Three 5-mm ports are placed under laparoscopic view: first, in the right upper quadrant below the costal arch (for liver retraction); next, in the midline just below the xiphoid process (for the surgeon’s left hand instrument); and, finally, along the left axillary line in the left lower quadrant (for gastric retraction). In the left upper quadrant, triangulated between the two-midline ports, the fifth port, a 10-mm port (for the surgeon’s right hand) is placed. The patient is positioned in a reverse Trendelenburg position allowing the bowel and other mobile abdominal contents to occupy the lower portions of the abdomen, providing a degree of “self retraction.” (Color version of figure is available online.)

3. The left lateral segment of the liver is retracted superiorly. The clear space (pars lucida) in the lesser omentum over the caudate lobe of the liver is opened. Using the harmonic scalpel, the lesser omentum is divided superiorly to the patient’s right of the esophagus. This exposes the right crus of the esophageal hiatus. Dissection may require division of the hepatic branch of the vagus nerve and an arterial branch of the left gastric artery to the left lateral segment of the liver.4(Color version of figure is available online.)

4. The peritoneum overlying the right crus is divided with the harmonic scalpel. Blunt mobilization is performed from the inferior portion of the right crus, where it merges with the left crus, to the apex of the hiatus. The esophagus and posterior vagus nerve are retracted to the patient’s left, facilitating the dissection. (Color version of figure is available online.)

5. With the esophagogastric junction retracted superiorly, the inferior and medial portions of the left crus are bluntly dissected. (Color version of figure is available online.)
This completes the hiatal dissection. These three steps indirectly mobilize the esophagus and may potentially reduce inadvertent esophagogastric injury. The esophagus is encircled with a penrose drain (18 cm long) which aids in retraction, and permits completion of the hiatal dissection.
Theoretically, since the myotomy is performed on the anterior gastrointestinal wall, the hiatal and esophageal mobilization are not necessary. The mobilization of the esophagus is significant and destroys at least 12 of the anchoring phrenoesophageal ligament. However, especially in elderly patients, there frequently is an associated hiatal hernia which will require simultaneous repair. In addition, the stabilization and retraction provided by the penrose drain facilitates myotomy. (Color version of figure is available online.)

6. The superior aspect of the left crus is dissected from the apex of the esophageal hiatus inferiorly to meet the mobilization described in

7. A 60 Fr. Maloney bougie is passed to assist myotomy. In the dilated sigmoid esophagus, blind passage of a bougie may not be possible; this requires esophagoscopy and placement of a guide wire over which a guided (Savary) bougie may be passed.
The harmonic scalpel is used to divide the fat pad in the midline over the esophagogastric junction. The anterior vagus nerve will now lie on the patient’s left in this esophagogastric tissue. The myotomy begins on the anterior wall of the esophagus approximately 2 cm above the esophagogastric junction. The longitudinal layer of the muscularis propria is split. This exposes the circular muscle, which can fractured by distraction between Maryland dissectors. The submucosa is uncovered. The identification of the plane between the muscularis propria and the submucosa is critical for successful myotomy. Although saline injection into the esophageal wall has been proposed as an aid to development of this plane, it is unnecessary and may, in fact, distort the anatomy and foster submucosal injury. The myotomy extends superiorly to the junction of the thoracic and abdominal esophagus and inferiorly to the esophagogastric junction by careful traction and fracture of the muscle layer. Electrocautery can be used in this process; however, care must be taken to avoid thermal injury to the submucosa that may result in a delayed esophageal leak. Usually, direct pressure on the bleeding muscle edge and pinpoint cautery of muscular vessels is sufficient for hemostasis. Since the extent of sonic injury to the submucosa is not appreciated at the time of myotomy the harmonic scalpel should not be used in this portion of the operation.
Although prior pneumatic dilation or Botulinum toxin injection has not been shown to affect outcome,5these treatments may obliterate the plane between the muscularis propria and submucosa.6If the initial site chosen for myotomy is at an unappreciated focus of fibrosis from prior treatment then the myotomy should be restarted laterally, in a new location, potentially removed from the site of previous therapy. (Color version of figure is available online.)

8. The key to relief of esophageal obstruction is the extension of the myotomy onto the stomach for 2 cm to 3 cm.7 Extending the myotomy here becomes extremely difficult because the muscle thins in this area and develops an oblique orientation. The appearance of transverse submucosal veins confirms that the proximal stomach is being myotomized. If these vessels are inadvertently injured, they should be controlled with vascular clips, not electrocautery. (Color version of figure is available online.)

9. Esophagogastroscopy verifies adequate length of the myotomy and integrity of the mucosa/submucosa layer. The use of the picture-in-picture function of the video monitor allows simultaneous viewings of the myotomy by esophagoscopy and by laparoscopy. Using this technique, myotomy length can be measured and sufficient gastric extension confirmed. Visual inspection of the mucosa and insufflation of the esophagogastric junction, while the area is immersed in saline will prove, the layer intact and airtight. This step is facilitated if the patient is placed in Trendeleberg position. (Color version of figure is available online.)

10. The esophageal hiatus is reapproximated by direct closure using nonabsorbable sutures of 0 or 1 size. The ideal suture length is 18 cm. (Color version of figure is available online.)

11. The construction of the Dor (partial anterior) fundoplication begins with the placement of a nonabsorbable 0 suture (22 cm long). This passes from the greater curve of the stomach to the left crus, close to its superior limit and to the left myotomy edge. This suture is tied with an intracorporeal technique that forms the left edge of the fundoplication. (Color version of figure is available online.)

12. The right side of the fundoplication is formed by a suture (18 cm long) passed from the gastric fundus (approximately 5 cm to 6 cm medial to the previous suture in the greater curve) to the right myotomy edge and to the right crus, close to its superior limit. A third suture (18 cm long) is placed from the superior aspect of the midportion of the fundoplication to the apex of the esophageal hiatus. (Color version of figure is available online.)

13. The completed Dor fundoplication. Incorporation of myotomy borders into the fundoplication distracts the myotomy and prevents healing of muscle edges together. The apposition of the gastric wall to the esophageal submucosa in the base of the myotomy provides a “serosal patch” that potentially protects against leak from a microperforation. (Color version of figure is available online.)

14. Timed barium esophagram is important for both diagnosis of achalasia and therapy assessment.8–10 A 39 year-old female with a 2-year history of dysphagia and regurgitation was misdiagnosed as gastroesophageal reflux. Ingestion of 250 mL of barium demonstrated a dilated, poorly emptying esophagus. At 1 minute, the entire extent of barium retention cannot be seen on one standard radiographic film. The height of the barium column is an estimated 18 cm (froth, which is barium coated saliva, is not included in this measurement) and the maximum width of the column is 10 cm. At 5 minutes there has been minimal emptying, with a barium column

15. Relief of symptoms provides an inaccurate evaluation of treatment.10,11 Timed barium esophagram gives a quantifiable assessment of esophageal emptying.

height of 17 cm and a width of 9 cm. Esophageal manometry confirmed the diagnosis of achalasia.

Definition

Bowel resection is a surgical procedure in which a diseased part of the large intestine is removed. The procedure is also known as colectomy, colon removal, colon resection, or resection of part of the large intestine.

Purpose
The large bowel, also called the large intestine, is a part of the digestive system. It runs from the small bowel (small intestine) to the rectum, which receives waste material from the small bowel. Its major function is to store waste and to absorb water from waste material. It consists of the following sections, any of which may become diseased:

• Colon. The colon averages some 60 in (150 cm) in length. It is divided into four segments: the ascending colon, transverse colon, descending colon, and sigmoid colon. There are two bends (flexures) in the colon. The hepatic flexure is where the ascending colon joins the transverse colon. The splenic flexure is where the transverse colon merges into the descending colon.

• Cecum. This is the first portion of the large bowel that is joined to the small bowel. The appendix lies at the lowest portion of the cecum.
• Ascending colon. This segment is about 8 in (20 cm) in length, and it extends upwards from the cecum to the hepatic flexure near the liver.
• Transverse colon. This segment is usually more than 18 in (46 cm) in length and extends across the upper abdomen to the splenic flexure.
• Descending colon. This segment is usually less than 12 in (30 cm) long and extends from the splenic flexure downwards to the start of the pelvis.
• Sigmoid colon. An S-shaped segment that measures about 18 in (46 cm); it extends from the descending colon to the rectum.
The wall of the colon is composed of four layers:
• Mucosa. This single layer of cell lining is flat and regenerates itself every three to eight days. Small glands lie beneath the surface.
• Submucosa. The area between the mucosa and circular muscle layer that is separated from the mucosa by a thin layer of muscle, the muscularis mucosa.
• Muscularis propria. The inner circular and outer longitudinal muscle layers.
• Serosa. The outer, single-cell, thick covering of the bowel. It is similar to the peritoneum, the layer of cells that lines the abdomen.
The large intestine is also responsible for bacterial production and absorption of vitamins. Resection of a portion of the large intestine (or of the entire organ) may become necessary when it becomes diseased. The exact

To remove a portion of the colon, or large intestine, and incision is made in the abdomen to expose the area

(A). Tissues and muscles connecting the colon to surrounding organs are severed (B). The area to be removed is clamped and severed (C). The remaining portions of the bowel, the ileum (small intestine) and transverse colon, are connected with sutures (D). Muscles and tissues are repaired (E).

reasons for large bowel resection in any given patient may be complex and are always carefully evaluated by the treating physician or team. The procedure is usually performed to treat the following disorders or diseases of the large intestine:

Cancer. Colon cancer is the second most common type of cancer diagnosed in the United States. Colon and rectum cancers, which are usually referred to as colorectal cancer, grow on the lining of the large intestine. Bowel resection may be indicated to remove the cancer.

Diverticulitis. This condition is characterized by the inflammation of a diverticulum, especially of diverticula occurring in the colon, which may undergo perforation with abscess formation. The condition may be relieved by resecting the affected bowel section.
Intestinal obstruction. This condition involves a partial or complete blockage of the bowel that results in the failure of the intestinal contents to pass through. It is usually treated by decompressing the intestine with suction, using a nasogastric tube inserted into the stomach or intestine. In cases where decompression does not relieve the symptoms, or if tissue death is suspected, bowel resection may be considered.
Ulcerative colitis. This condition is characterized by chronic inflammation of the large intestine and rectum resulting in bloody diarrhea. Surgery may be indicated when medical therapy does not improve the condition. Removal of the colon is curative and also removes the risk of colon cancer. About 25–40% of ulcerative colitis patients must eventually have their colons removed because of massive bleeding, severe illness, rupture of the colon, or risk of cancer.

Traumatic injuries. Accidents may result in bowel injuries that require resection.
Pre-cancerous polyps. A colorectal polyp is a growth that projects from the lining of the colon. Polyps of the colon are usually benign and produce no symptoms, but they may cause rectal bleeding and develop into malignancies over time. When polyps have a high chance of becoming cancerous, bowel resection may be indicated.
Familial adenomatous polyposis (FAP). This is a hereditary condition caused by a faulty gene. Most people discover that they have it at a young age. People with FAP grow many polyps in the bowel. These are mostly benign, but because there are so many, it is really only a question of time before one becomes cancerous. Since people with FAP have a very high risk of developing bowel cancer, bowel resection is thus often indicated.
Hirschsprung’s disease (HD). This condition usually occurs in children. It causes constipation, meaning that bowel movements are difficult. Some children with HD cannot have bowel movements at all; the stool creates a blockage in the intestine. If HD is not treated, stool can fill up the large intestine and cause serious problems such as infection, bursting of the colon, and even death.
Description
Bowel resection can be performed using an open surgical approach (colectomy) or laparoscopically.

Colectomy

Following adequate bowel preparation, the patient is placed under general anesthesia, which ensures that the patient is deep asleep and pain free during surgery. Because the effects of gravity to displace tissues and organs away from the site of operation are important, patients are carefully positioned, padded, and strapped to the operating table to prevent movement as the patient is tilted to an extreme degree. The surgeon starts the procedure by making a lower midline incision in the abdomen or, alternatively, he may prefer to perform a lateral lower transverse incision instead. He proceeds with the removal of the diseased portion of the large intestine, and then sutures or staples the two healthy ends back together before closing the incision.

The amount of bowel removed can vary considerably, depending on the reasons for the operation. When possible, the procedure is performed to maintain the continuity of the bowel so as to preserve normal passage of stool. If the bowel has to be relieved of its normal digestive work while it heals, a temporary opening of the colon onto the skin of abdominal wall, called a colostomy , may be created. In this procedure, the end of the colon is passed through the abdominal wall and the edges are sutured to the skin. A removable bag is attached around the colostomy site so that stool may pass into the bag, which can be emptied several times during the day. Most colostomies are temporary and can be closed with another operation at a later date. However, if a large portion of the intestine is removed, or if the distal end of the colon is too diseased to reconnect to the proximal intestine, the colostomy is permanent.

Laparoscopic bowel resection

The benefits of laparoscopic bowel resection when compared to open colectomies include reduced postoperative pain, shorter hospitalization periods, and a faster return to normal activities. The procedure is also minimally invasive. When performing a laparoscopic procedure, the surgeon makes three to four small incisions in the abdomen or in the umbilicus (belly button). He inserts specialized surgical instruments , including a thin, telescope-like instrument called a laparoscope, in an incision. The abdomen is then filled with gas, usually carbon dioxide, to help the surgeon view the abdominal cavity. A camera is inserted through one of the tubes and displays images on a monitor located near the operating table to guide the surgeon as he works. Once an adequate view of the operative field is obtained, the actual dissection of the colon can start. Following the procedure, the small incisions are closed with sutures or surgical tape.
All colon surgery involves only three maneuvers that may vary in complexity depending on the region of the bowel and the nature of the disease. These three maneuvers are:

• retraction of the colon
• division of the attachments to the colon
• dissection of the mesentery

In a typical procedure, after retracting the colon, the surgeon proceeds to divide the attachments to the liver and the small bowel. Once the mesenteric vessels have been dissected and divided, the colon is divided with special stapling devices that close off the bowel while at the same time cutting between the staple lines. Alternatively, a laparoscopically assisted procedure may be selected, in which a small abdominal wall incision is made at this point to bring the bowel outside of the abdomen, allowing open bowel resection and reconnection using standard instruments. This technique is popular with many surgeons because an incision must be made to remove the bowel specimen from the abdomen, which allows the most time-consuming and risky parts of the procedure (from an infection point of view) to be done outside the body with better control of the colon.

Diagnosis/Preparation

Key elements of the physical examination before surgery focus on a thorough examination of the abdomen, groin, and rectum. Other common diagnostic tools used to evaluate medical conditions that may require bowel resection include imaging tests such as gastrointestinal barium series, angiography , computerized tomography (CT), magnetic resonance imaging (MRI), and endoscopy.

As with any surgery, the patient is required to sign a consent form. Details of the procedure are discussed with the patient, including goals, technique, and risks. Blood and urine tests, along with various imaging tests and an electrocardiogram (EKG), may be ordered. To prepare for the procedure, the patient is asked to completely clean out the bowel. This is a crucial step if the bowel is to be opened safely within the peritoneal cavity, or even manipulated safely through small incisions. To empty and cleanse the bowel, the patient is usually placed on a low-residue diet for several days prior to surgery. A liquid diet may be ordered for at least the day before surgery, with nothing taken by mouth after midnight. A series of enemas and/or oral preparations (GoLytely or Colyte) may be ordered to empty the bowel of stool. Preoperative bowel preparation involving mechanical cleansing and administration of intravenous antibiotics immediately before surgery is the standard practice. The patient may also be given a prescription for oral antibiotics (neomycin, erythromycin, or kanamycin sulfate) the day before surgery to decrease bacteria in the intestine and to help prevent post-operative infection. A nasogastric tube is inserted through the nose into the stomach during surgery and may be left in place for 24–48 hours after surgery. This removes the gastric secretions and prevents nausea and vomiting. A urinary catheter (a thin tube inserted into the bladder) may be inserted to keep the bladder empty during surgery, giving more space in the surgical field and decreasing chances of accidental injury.

Aftercare

Postoperative care for the patient who has undergone a bowel resection, as with those who have had any major surgery, involves monitoring of blood pressure, pulse, respiration, and temperature. Breathing tends to be shallow because of the effect of anesthesia and the patient’s reluctance to breathe deeply and experience pain that is caused by the abdominal incision. The patient is instructed how to support the operative site during deep breathing and coughing, and is given pain medication as necessary. Fluid intake and output is measured, and the operative site is observed for color and amount of wound drainage. The nasogastric tube will remain in place, attached to low intermittent suction until bowel activity resumes. Fluids and electrolytes are infused intravenously until the patient’s diet can gradually be resumed, beginning with liquids and advancing to a regular diet as tolerated. The patient is generally out of bed approximately eight to 24 hours after surgery. Most patients will stay in the hospital for five to seven days, although laparoscopic surgery can reduce that stay to two to three days. Postoperative weight loss follows almost all bowel resections. Weight and strength are slowly regained over a period of months. Complete recovery from surgery may take two months. Laparoscopic surgery can reduce this time to one to two weeks.

The treating physician should be informed of any of the following problems after surgery:

• increased pain, swelling, redness, drainage, or bleeding in the surgical area
• headache, muscle aches, dizziness, or fever
• increased abdominal pain or swelling, constipation, nausea or vomiting, rectal bleeding, or black, tarry stools

Risks

Potential complications of bowel resection surgery include:
• excessive bleeding
• surgical wound infection
• incisional hernia (an organ projecting through the surrounding muscle wall, it occurs through the surgical scar)
• thrombophlebitis (inflammation and blood clot to veins in the legs)
• narrowing of the opening (stoma)
• pneumonia
• pulmonary embolism (blood clot or air bubble in the lung blood supply)
• reaction to medication
• breathing problems
• obstruction of the intestine from scar tissue

DISEASES OF THE COLON

Several diseases can interfere with the normal functioning of the colon. These diseases can have various effects and are classified as benign (noncancerous) or malignant (cancerous). They can cause symptoms including bleeding, infection, and perforation.
In some cases, doctors treat the disease by removing a segment of the colon. Given that the average person has 8-10 feet of small bowel and 3-5 feet of colon, removing a segment generally doesn’t effect normal colon functioning.

CROHN’S DISEASE AND ULCERATIVE COLITIS

BACKGROUND: INFLAMMATORY BOWEL DISEASE (IBD) INCLUDES CROHN’S DISEASE AND ULCERATIVE COLITIS

Inflammatory bowel disease (IBD) is caused by chronic inflammation of the intestinal tract. There are two forms of inflammatory bowel disease: Crohn’s disease and ulcerative colitis (UC).

Crohn’s disease and ulcerative colitis are similar — so similar that they’re often mistaken for one another. Both diseases cause inflammation of the lining of your digestive tract, and both may result in severe bouts of diarrhea and abdominal pain.

Crohn’s disease can occur anywhere in your digestive tract, often spreading deep into the layers of affected tissues. Ulcerative colitis, on the other hand, usually affects only the innermost lining of your large intestine (colon) and rectum.
CLINICAL PRESENTATION: THE COMMON SIGNS AND SYMPTOMS OF INFLAMMATORY BOWEL DISEASE
PATIENTS WITH INFLAMMATORY BOWEL DISEASE COULD PRESENT WITH ANY OF THE FOLLOWING:
Abdominal pain
Nausea, vomiting
Diarrhea, bloody stool
Weight loss or weight gain
Various associated complaints or diseases, often autoimmune disorders (arthritis, skin lesions, and liver and bile duct disorders).
In Crohn’s disease, inflammation causes cells in the affected areas of your intestine to secrete large amounts of water and salt. Because the colon can’t absorb this excess fluid, you develop diarrhea. Altered intestinal contractions also can contribute to loose stools. Diarrhea can range from mild to severe.
Diarrhea can also be a symptom of ulcerative colitis. However, patients with ulcerative colitis tend to experience bloody diarrhea and also something called tenesmus. Tenesmus is the sensation of having to move one’s bowels.
Food moving through your digestive tract can cause inflamed tissue to bleed, and your bowel may also bleed on its own. You might notice bright red blood in the toilet bowl or darker blood mixed with your stool. Should this occur, you must notify your physician.
TREATMENT: WHAT NEEDS TO BE DONE IF YOU HAVE INFLAMMATORY BOWEL DISEASE
MEDICAL THERAPY:
Usually, treatment of inflammatory bowel disease begins with medical therapy. Most commonly, treatment of inflammatory bowel disease requires mesalamine or Asacol® (mesalazine), which in part also acts as an anti-inflammatory agent.
Depending on the level of severity, inflammatory bowel disease may require immunosuppression to control the symptoms. Immunosupression refers to using medications to depress the body’s ability to generate an inflammatory response. Such medications often used include azathioprine, methotrexate, or 6-mercaptopurine. If initial treatment is unsuccessful, a combination of the aforementioned immunosupression drugs may or may not be administered, depending on the patient.
During times of acute exacerbation of inflammatory bowel disease, steroids are often used to control disease flares. Remicade® (infliximab), another type of anti-inflammatory, has been used for many years in Crohn’s disease and more recently also in patients with ulcerative colitis.
Severe cases may require surgery, such as bowel resection of the diseased portion of intestines, and/or temporary or permanent colostomy or ileostomy.
SURGICAL THERAPY: CROHN’S DISEASE

Surgery for Crohn’s disease is recommended in carefully selected cases because the disease can recur in any remaining portion of the gastrointestinal tract.
Surgery is recommended when Crohn’s related complications occur. This includes infection (abscess), perforation, blockage or obstruction and possible fistula (connection between bowel and other structures).

SURGICAL THERAPY: ULCERATIVE COLITIS

• Of the two conditions, patients with ulcerative colitis are more likely to undergo surgery because removal of the colon and rectum will cure the disease.
• Surgery for ulcerative colitis usually entails removing the entire colon. There are different ways to remove the colon as well as different ways to put the colon back together.
• The surgery that was traditionally performed for ulcerative colitis was a proctocolectomy which removed the entire colon, rectum and anus. However, this operation required the creation of an ileostomy. This is an opening in the small intestine that is brought up to the skin where waste is expelled. This opening requires a bag to be worn over the opening in the skin to collect waste.
• Another surgical option would be to create an ileostomy with an internal pouch that acts as a collecting system. This eliminates the need for a bag; however, the opening in the skin still exists. Defecation is maintained by the patient on a schedule.
• A different surgical approach would be to only remove the large intestine (colon) leaving the rectum and anus. The small intestine (ileum) would then be connected to the rectum. This relieves the patient of having to live with a colostomy but leaves large intestine behind that may be susceptible to recurrent ulcerative colitis. Thus, frequent surveillance colonoscopy is required.
• A newer and more appealing surgical procedure is called an Ileo-anal J pouch. This operation removes the large intestine and rectum but leaves the anus. The small intestine is then connected to the anus and fashioned into a pouch capable of storing feces.
• Most of these operations can be done either open or laparoscopically. Laparoscopic surgery for ulcerative colitis has shown similar long term outcomes when compared to open surgery. As with other types of minimally invasive surgery, laparoscopic surgery usually results in shorter hospital stays and shorter recoveries.
• It is important to note that not all procedures can be done laparoscopically and the decision should always be discussed between patient and surgeon.

RISKS OF SURGERY FOR ULCERATIVE COLITIS

The risks of any surgery must be weighed against the risks associated with disease state requiring the intervention.
In the case of ulcerative colitis, the risks of ongoing inflammation, infection and subsequent colon cancer are sometimes greater than the risks described below and surgery is thus indicated.
• Major risks of laparoscopic proctocolectomy with ileoanal J pouch for ulcerative colitis can include but are not limited to:
• Wound infection (1-3%) possibly requiring opening of wound, drainage, antibiotics and prolonged wound care.
• Abdominal cavity infection (1-3%) possibly requiring antibiotics, drainage of the infection via a catheter or re-operation to drain the infection.
• Leakage from the re-connection points (anastomotic leak) (5-10%) resulting in infection and possibly drainage of the infection via a catheter or re-operation to drain the infection. Re-operation may also require creation of a temporary colostomy to allow the body time to heal the infection. This can typically be reversed 4-6 months later.
• Bleeding from surgical sites (1-3%) requiring observation, blood transfusion or re-operation.
• Pouchitis or inflammation of the J pouch (25%) with subsequent diarrhea and possible leakage of mucous and stool from the anus.

DIVERTICULITIS

Diverticulitis is a common gastrointestinal disorder found mainly in the left side of the large intestine, primarily the sigmoid colon. Diverticulitis develops from a condition called diverticulosis, which involves the formation of outpouches of the colon wall. Diverticulolsis is quite common and tends to occur after the age of 50. Diverticulitis results if one or more of these pouches (or diverticula) becomes inflamed. While left sided involvement is the rule, some patients may have diverticulosis and subsequent diverticulitis on the right side of the colon.

Risk factors believed to be important for developing diverticulosis includes: aging, low fiber diet and possibly lack of exercise. There are no known factors that cause diverticulosis to become diverticulitis.
THE COMMON SIGNS AND SYMPTOMS OF DIVERTICULITIS

PATIENTS OFTEN PRESENT WITH THE CLASSIC TRIAD OF SYMPTOMS:

1. Left sided abdominal pain mainly over the lower left side (also known as left lower quadrant pain).
2. Fever
3. An elevation of the white cell count (blood test).

Patients may also complain of nausea or diarrhea; others may be constipated.
Other symptoms could include: vomiting, bloating, bleeding from your rectum, frequent urination, and difficulty or pain with urination.

TESTS TO PROVE WHETHER YOU HAVE DIVERTICULITIS

Patients with the above symptoms are commonly studied with a computed tomography, or CT scan. The CT scan is very sensitive (it will detect 98% of all patients with diverticulitis).
Your doctor may also choose to obtain a barium enema. In this test, x-ray dye (barium) is injected through the rectum and pictures are taken to study the inside of the colon. While this test is sensitive for the diagnosis, it does not give information about the overall extent of the disease.
Your doctor should discuss the reasons for choosing one of these tests versus another.

WHAT NEEDS TO BE DONE IF YOU HAVE DIVERTICULITIS

Medical Management

A first time episode of diverticulitis is usually treated with conservative medical management, including bowel rest (i.e., ranging from nothing by mouth to liquids only), intravenous fluid, and antibiotics. Depending on the severity of your attack, this treatment plan may or may not require hospital admission.
Once your pain begins to resolve, most patients will be placed on a low residue diet. This low-fiber diet gives the colon adequate time to heal without needing to be overworked. Later, patients are typically placed on a high fiber diet as there is some evidence this lowers the risk for second and third attacks, known as recurrence.

Patient suffering one-time attacks typically do not require surgery so long as the attack resolved with medical therapy. Recurring attacks or more severe first-time cases may require surgery, either immediately or on an elective basis (see below). The decision to perform surgery for diverticulitis is always handled on a patient by patient basis so you should discuss your specific case with your doctor.
Surgical Therapy

In some cases, surgery may be required to remove the area of the colon most affected by the disease. For example, if the involved segment is the sigmoid colon, the procedure is known as a sigmoid colectomy.
You should understand that segmental colectomy only involves removing the infected or thickened area. Surgeons routinely leave other areas of diverticulosis behind to avoid removing large amounts of your colon. Only 4% of people who have surgery will have a repeat attack in the remaining bowel. However, repeat surgery is not usually warranted.

When is Surgery Indicated?

• Repeated attacks of diverticulitis, (surgery usually advised after two to four attacks).
• Diverticulitis causing partial or complete bowel blockage (obstruction).
• Infected diverticulum leading to perforation of bowel contents into abdominal cavity, (also known as peritonitis or abdominal sepsis).
• Communication (fistula) between the affected bowel and any surrounding organs such as bladder, uterus, skin.
SURGERIES

Emergency Colectomy:

In more emergent cases, when there has been perforation to the intestine from diverticultis, two operations are usually involved.
• The first operation takes care of the immediate problem by removing the infected bowel. Due to the local inflammation and infection in such situations, the bowel is usually not healthy enough to reattach and the patient is left with a colostomy. A colostomy is a temporary situation in which the end of the colon is brought up to the skin. Stool will pass through the colon through this hole or stoma into an attached bag. This will typically be left in place for 4-6 months to allow the infection and inflammation on the inside to heal.
• The second operation entails putting the colon back together. This operation can be performed either open (through an incision) or laparoscopic (through multiple small incisions). This decision will be left to you and your surgeon.
Elective Colectomy:
More typically, elective surgery for diverticulitis occurs. As discussed above, this is called segmental colectomy and can be performed either open or laparoscopically.
In open surgery, a large abdominal incision is made. Through this incision the surgeon is able to remove the diseased intestine. Once the diseased bowel is removed the remaining colon is reconnected. With this, the patient is able to have normal bowel movements, the same as before the surgery.
In laparoscopic surgery, 3-5 small incisions are made in the abdominal wall through which instruments and a viewing tube (laparoscope) are inserted. A camera attached to the viewing tube sends images of the inside of the abdomen to a television screen. The surgeon looks at the screen to see what he or she is doing while using the instruments to perform the surgery.

Recent studies show that when laparoscopic colectomy is performed by an appropriately trained surgeon, the short- and long-term outcomes are better than with open surgery. This stems from shorter recovery time, reduced length of hospital stay and earlier return to daily activities. You should ask your surgeon about this approach and about his personal skill level and experience with laparoscopic colectomy.
RISKS OF LAPAROSCOPIC COLECTOMY FOR DIVERTICULITIS
The risks of any surgery must be weighed against the risks associated with disease state requiring the intervention. In the case of recurrent complicated diverticulitis, the risks of ongoing inflammation and infection are greater than the risks described below and surgery is thus indicated.
Major risks of laparoscopic colectomy for diverticulitis can include but are not limited to:
• Wound infection (1-3%) possibly requiring opening of wound, drainage, antibiotics and prolonged wound care.
• Abdmominal cavity infection (1-3%) possibly requiring antibiotics, drainage of the infection via a catheter or reoperation to drain the infection.
• Leakage from the re-connection points (anastomotic leak) (1-2%) resulting in infection and possibly drainage of the infection via a catheter or re-operation to drain the infection. Re-operation may also require creation of a temporary colostomy to allow the body time to heal the infection. This can typically be reversed 4-6 months later.
• Bleeding from surgical sites (1-3%) requiring observation, blood transfusion or re-operation.
• Recurrence of diverticultis (10%) in adjacent or remote areas of the colon requiring additional medical or surgical therapy

POLYPS AND HOW THEY RELATE TO COLORECTAL CANCER

Colorectal cancer is cancer of the large intestine (colon), the lower part of your digestive system. Rectal cancer is cancer of the last part of your colon. Together, colorectal cancer is the #2 cause of cancer-related deaths in the United States (second to lung cancer.)
In most cases of colon cancer, the process begins in the form of a polyp. These are benign (non-cancerous) clumps of cells that are often small, and produce few symptoms other than silent and slow bleeding (which may manifest as dark stool.)

POLYPS ARE OF 2 MAIN TYPES AND MAY BE HYPERPLASTIC OR ADENOMATOUS.

• Hyperplastic polyps are benign and have no potential to develop into cancer.
• Adenomatous polyps come in different varieties all of which have the potential to develop into cancer.
It is not possible to distinguish adenomatous from hyperplastic polyps in the body so the current standard of care is to completely remove any colon polyps to permit complete analysis.
On occasion, it may be found that colon cancer has already developed in a removed polyp. In such cases, if the cancer has been completely removed, no further tissue removal is necessary. In cases where residual cancer is left, or if there is uncertainty if cancer cells remain, removal of the affected portion of the colon is indicated (see below.)
Screening tests, as well as simply lifestyle and diet changes, can greatly reduce your overall risk of developing colon cancer because most polyps can be found and removed before they turn into cancer.
SIGNS AND SYMPTOMS OF COLON POLYPS / COLORECTAL CANCER
Polyps rarely cause symptoms by themselves. On occasion, polyps may bleed and this will typically manifest as dark or tarry stool. Such a finding should prompt a phone call to your physician.
There are often no symptoms of colorectal cancer during its early stages. When symptoms do occur, they will vary according to the location and size of the cancer.
Symptoms may include:
• Prolonged changes in your normal bowel habits, including diarrhea or constipation.
• Changes in size or shape of bowel movements (i.e., narrow, pencil thin stools).
• Persistent abdominal pain or distention.
• Rectal bleeding or blood in your stool – either bright red or dark depending on where to cancer is located.
• Unexplained weight loss or change in appetite.
RISK FACTORS
There are many factors that may influence the development of colon cancer. Some include:
• Age: your chance of having colorectal cancer goes up over the age of 50.
• Family history: your risk is higher if a close family member (sibling, parent) has colon cancer.
• History of colonic polyps: certain polyps increase the risk of cancer, especially if they are large or come in large numbers.
• Inflammatory bowel disease: long standing history of ulcerative colitis or Crohn’s disease is associated with increased risk.
• Diabetes: people with diabetes have a 40% increased risk of colon cancer.
• Diet: a diet high in fats (especially animal fats) may increase your risk for colon cancer.
• Cigarette smoking / alcohol: may increase your risk.
• Sedentary lifestyle.
• Race: African Americans have the highest number of colorectal cancer cases in the United States and the reason is still unknown.
SCREENING AND DIAGNOSIS
Most colon cancers develop from adenomatous polyps, so early and routine screening is very important for detecting colon cancers. Common screen procedures include:
Digital rectal exam: This is done in the office and is usually painless. A doctor uses a gloved finger to examine the last few inches of your rectum. This exam cannot detect polyps or abnormalities higher in your colon/ rectum.
Fecal occult blood test: This test checks your stool sample for hidden blood. Very small amounts of blood can be in the stool when polyps or cancers start to form. It can either be done in the doctor’s office or by yourself at home using a special kit. If the results are positive for blood, further test are needed to find the exact cause of bleeding.
Flexible sigmoidoscopy: This test is typically done in the office. Your doctor uses a slender lighted tube attached to a video camera so that he/she can examine your rectum and sigmoid colon. If a polyp or abnormality is found, you will be recommended to undergo a formal colonoscopy to examine the entire colon and rectum, and to remove or biopsy any polyps detected.
Colonoscopy: This is the most comprehensive and sensitive test for colon cancer. The instrument is a longer version of the flexible sigmoidoscopy and allows the entire length of the colon and rectum to be examined. The day before, you will be asked to undergo a bowel prep to clean out your colon. And during the procedure, you will receive a mild sedative to make the procedure more comfortable. Most patients go home the same day.
TREATMENT FOR COLORECTAL CANCER

There are four main types of treatment for colorectal cancer:

• Surgery
• Radiation therapy
• Chemotherapy
• Targeted Drug Therapy
The treatment or combination of treatments depends on the stage or extent of cancer present: location of the cancer, how far the cancer has penetrated into the wall of the bowel, and whether the cancer has spread to the lymph nodes and other parts of your body.

TREATMENT FOR COLORECTAL CANCER: SURGERY

Surgery is the main treatment option for colon cancer.
Segmental Colectomy is a surgical procedure that removes the part of your colon that contains the cancer, plus a margin of healthy colon on either side to make sure no cancer is left behind. The two ends of colon are typically then reconnected.
Traditionally, surgery for colon cancer has been done through one large incision in the abdomen. More recently, several large scale studies have been done to prove that laparoscopic surgery can be used to safely remove colon cancer and reattach the ends.1This is known as a laparoscopic colectomy. In each of the studies, researchers have shown that colon cancer patients treated by laparoscopic colectomy have the same propensity for survival as those treated with open colectomy but receive all the benefit of the quicker recovery of a laparoscopic operation.

In laparoscopic colectomy, surgeons utilize special instruments and cameras that are inserted inside the body through multiple small incisions, rather than one large incision. Patients usually recover faster after this technique and leave the hospital earlier on average than patients who choose open surgery. The cosmetic benefits also apply. Not everyone is a candidate for laparoscopic colectomy. People who have large tumors or those who have had many abdominal surgeries in the past, may not be candidates for this technique. This should be discussed with your surgeon as the decision is always dependent on your unique situation and your surgeon’s level of comfort.

RISKS OF LAPAROSCOPIC COLECTOMY FOR COLON POLYPS OR COLON CANCER

The risks of any surgery must be weighed against the risks associated with disease state requiring the intervention. In the case of polyps or cancer, the risks of developing or leaving known cancer in the body are greater than the risks described below and surgery is thus indicated.
Major risks of laparoscopic colectomy for colon polyps or cancer can include, but are not limited to:
• Wound infection (1-3%) possibly requiring opening of wound, drainage, antibiotics and prolonged wound care.
• Abdmominal cavity infection (1-3%) possibly requiring antibiotics, drainage of the infection via a catheter or reoperation to drain the infection.
• Leakage from the re-connection points (anastomotic leak) (5-10%) resulting in infection and possibly drainage of the infection via a catheter or re-operation to drain the infection. Re-operation may also require creation of a temporary colostomy to allow the body time to heal the infection. This can typically be reversed 4-6 months later.
• Bleeding from surgical sites (1-3%) requiring observation, blood transfusion or re-operation.
TREATMENT FOR RECTAL CANCER: RADIATION THERAPY
Radiation is typically reserved for patients with rectal cancer only because it is dangerous to radiate the small bowel that comes in contact with the areas of the colon other than the rectum. Radiation therapy involves treatment with powerful energy rays that kill cancer cells.
If the cancer is large or if the cancer’s location makes surgical treatment difficult, radiation therapy may shrink the tumor before surgery.
There are two main types of radiation therapy, depending on the source of the high energy rays:
• External radiation therapy is used most commonly for people with colorectal cancer. Treatments are typically given 5 days a week for several weeks. Each treatment lasts only a few minutes.
• Internal radiation therapy involves placing small seeds of radioactive material directly into or near the cancer.
This allows high energy rays to focus directly onto the tumor. This technique is more frequently used with rectal cancer, prostate cancer, and in older or ill patients who would not be able to withstand surgery.
Radiation therapy causes several side effects: nausea, skin irritation, diarrhea, rectal or bladder irritation, or fatigue

TREATMENT FOR COLORECTAL CANCER: CHEMOTHERAPY

Also known as “chemo” and is the use of drugs that kill cancer cells. They may be given intravenously or taken by mouth. The drugs penetrate through the bloodstream, making them effective for cancers that have spread throughout the body.
Chemotherapy after surgery can increase the survival rate for some patients with invasive colorectal cancer. However, there are negative aspects to chemotherapy as well. While killing cancer cells, chemotherapy drugs can also damage normal, healthy cells too. This leads to side effects such as:

• Nausea, vomiting
• Fatigue
• Diarrhea
• Hair loss
• Increased risk of infection
• Bleeding or bruising
• Mouth sores / ulcers

Stomach Tumors, Masses, and Lesions

WHAT IS GASTRIC SURGERY?

Gastric Surgery refers to any type of surgery performed on the stomach. It is generally performed to remove tumors or masses or to treat those with stomach ulcer disease. A surgical removal of the stomach is called a gastrectomy. This type of surgery may remove the entire stomach or only that portion which is diseased and reconstruct the organ so that it will be able to function in as normal a manner as possible. For those with any type of stomach cancer, this type of surgery is a standard treatment. Dr. Sharona Ross and Dr. Alexander Rosemurgy are experts at minimally invasive surgery for this type of situation, which involves making one incision through the umbilicus as opposed to the large incision through skin and muscle that is made in conventional surgeries.

A stomach ulcer is an open sore found in the lining of the stomach. Without proper treatment, lesions can result in bleeding, perforation, swelling and scarring which causes a narrowing and obstruction of the intestinal opening. Various types of laparoscopic surgery can be performed to treat stomach lesions which do not respond to other treatments. Our Tampa laparoscopic surgeons are experienced in undertaking all types of stomach surgeries to handle this condition.

What to expect after an operation for your stomach:

Some patients but not all experience one or more of the listed symptoms below:
1. Early full sensation (early satiety) – with little or no remaining stomach you will have the sensation of feeling full faster.
2. Higher frequency of bowel movements – due to the nature of the reconstruction of your GI tract, your food will have faster transit. Long road trips or flights may require frequent trips to the restroom.
3. Nausea and/or vomiting may occur after surgery for 1-2 days. This is usually related to the general anesthesia administered during the operation.
4. Anemia – A specific cell type, important for B12 absorption, is present in your stomach. When a portion or the entire stomach is removed so is the cell type, resulting in poor B12 absorption and therefore anemia. Blood levels will need to be checked by your doctor for 6 months after your operation.
5. Iron deficiency – Normally the gastric acid prompts the body to break down dietary iron so it is absorbable for the intestines. If some or all of the stomach is removed less acid will be produced therefore the dietary iron will not be broken down as efficiently.
6. High carbohydrate meals such as pasta, sweets, and bread may cause abdominal pain and nausea, as well as flushing and dizziness. You should avoid meals and foods that are high in carbohydrates and sugars.

If you or a loved one has been diagnosed with stomach ulcer/tumor/cancer and need surgery as a treatment for the disease, we urge you to consult with us at our office at your earliest opportunity. We serve patients in the greater Tampa area as well as those throughout the state of Florida. Dr. Sharona Ross and Dr. Alexander Rosemurgy and their surgical team are experienced in performing advanced upper GI, pancreatic, gall bladder and liver surgeries.

• A splenectomy is surgery to remove the entire spleen, a delicate, fist-sized organ that sits under the left rib cage near the stomach. The spleen is an important part of the body’s defense (immune) system. It contains special white blood cellsthat destroy bacteria and help the body fight infections when you are sick. It also helps remove, or filter, old red blood cells from the body’s circulation.
• If only part of the spleen is removed, the procedure is called a partial splenectomy.
• Unlike some other organs, like the liver, the spleen does not grow back (regenerate) after it is removed.
• Up to 30% of people have a second spleen (called an accessory spleen). These are usually very small, but may grow and function when the main spleen is removed. Rarely, a piece of the spleen may break off with trauma, such as after a car accident. If the spleen is removed, this piece can grow and function.
• Who Needs a Splenectomy?
• You may need to have your spleen removed if you have an injury that damages the organ, causing its covering to break open, or rupture. A ruptured spleen can lead to life-threatening internal bleeding. Common injury-related causes of a ruptured spleen include car accidents and severe blows to the abdomen during contact sports, such as football or hockey.
• A splenectomy may also be recommended if you have cancer involving the spleen or certain diseases that affect blood cells. Certain conditions can cause the spleen to swell, making the organ more fragile and susceptible to rupture. In some cases, an illness, such as sickle cell disease, can cause the spleen to shrivel up and stop functioning. This is called an auto-splenectomy.
• The most common disease-related reason for a spleen removal is a blood disorder called idiopathic thrombocytopenic purpura (ITP). This is an autoimmune condition in which antibodies target blood platelets. Platelets are needed to help blood to clot, so a person with ITP is at risk for bleeding. The spleen is involved in making these antibodies and removing the platelets from the blood. Removing the spleen can be done to help treat the condition.
Other common reasons a person may need a spleen removal include:

Blood disorders:

• Hereditary elliptocytosis (ovalocytosis)
• Hereditary nonspherocytic hemolytic anemia
• Hereditary spherocytosis
• Thalassemia (Mediterranean anemia, or Thalassemia major)
Blood vessel problems:
• Aneurysm in the spleen’s artery
• Blood clot in the spleen’s blood vessels
Cancer:
• Leukemia, a blood cancer that affects cells that help the body fight infections.
• Certain types of lymphoma, a cancer that affects cells that help the body fight infections.

Before a Splenectomy

If your doctor thinks you have a ruptured spleen and you have signs of massive internal bleeding or unstable vital signs, such as low blood pressure, you will likely have spleen surgery right away.
In other cases, a complete physical exam, blood work, and tests to look at your abdominal and chest area will be done before surgery. The exact tests you have depend on your age and condition but may include a chest X-ray, electrocardiogram (EKG), magnetic resonance imaging (MRI) scan, and computed tomography (CT) scan.
You may need to follow a special liquid diet and take medication to clean out your bowels prior to the procedure. You should not eat or drink anything the morning of surgery. Your doctor will give you complete instructions.
Before surgery, you will be given drugs or a vaccine to prevent bacterial infections from developing after the spleen is removed.
How Is a Splenectomy Performed?
You will be given general anesthesia a few minutes before surgery so you are asleep and do not feel pain while the surgeon is working on you.
There are two ways to perform a splenectomy: laparoscopic surgery and open surgery.

Laparoscopic splenectomy is done using an instrument called a laparoscope. This is a slender tool with a light and camera on the end. The surgeon makes three or four small cuts in the abdomen, and inserts the laparoscope through one of them. This allows the doctor to look into the abdominal area and locate the spleen. Different medical instruments are passed through the other openings. One of them is used to deliver carbon dioxide gas into the abdominal area, which pushes nearby organs out of the way and gives your surgeon more room to work. The surgeon disconnects the spleen from surrounding structures and the body’s blood supply, and then removes it through the largest surgical opening. The surgical openings are closed using stitches or sutures.
Sometimes during laparoscopic splenectomy the doctor has to switch to the open procedure. This may happen if you have bleeding problems during the operation.
Open splenectomy requires a larger surgical cut than the laparoscopic method. The surgeon makes an incision across the middle or left side of your abdomen underneath the rib cage. After locating the spleen, the surgeon disconnects it from the pancreas and the body’s blood supply, and then removes it. The surgical openings are closed using stitches or sutures.

Laparoscopy vs. Open Surgery

Laparoscopy is less invasive than open surgery, and usually results in less pain, a faster recovery, and a shorter hospital stay. But not everyone can have laparoscopic surgery. Which method you and your doctor choose depends on your overall health and the size of your spleen. It can be hard to remove a very large or swollen spleen using a laparoscope. Patients who are obese or who have scar tissue in the spleen area from a previous operation also may not be able to have their spleen removed laparoscopically.

Recovering After a Splenectomy

After surgery, you will stay in the hospital for a while so doctors can monitor your condition. You will receive fluids through a vein, called an intravenous (IV) line, and pain medications to ease any discomfort.
How long you stay in the hospital depends on which type of splenectomy you have. If you have an open splenectomy, you may be sent home within one week. Those who have a laparoscopic splenectomy are usually sent home sooner.
It will take about four to six weeks to recover from the procedure. Your surgeon may tell you not to take a bath for a while after surgery so the wounds can heal. Showers may be OK. Your health care team will tell you if you need to temporarily avoid any other activities, such as driving.

Splenectomy Complications

You can live without a spleen. But because the spleen plays a crucial role in the body’s ability to fight off bacteria, living without the organ makes you more likely to develop infections, especially dangerous ones such as Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae. These bacteria cause severe pneumonia, meningitis, and other serious infections. Vaccinations to cover these bacteria should ideally be given to patients about two weeks before planned surgery or roughly two weeks after emergency surgery. Your doctor may recommend other immunizations as well.

Laparoscopic Adrenalectomy

The preferred operation for benign adrenal tumors.
A benign adrenal cortical tumor is shown in this picture which also shows the entire triangular adrenal gland. This tumor produced very large amounts of the hormone “aldosterone” which helps maintain salt balance in the blood when produced in normal amounts. Production of excess aldosterone by these tumors causes high blood pressure, high serum sodium, and low serum potassium. This tumor was removed laparoscopically through a series of 5 incisions each about 1/2 inch in length. The operation took 1.8 hours and the patient went home the next day cured of their disease.

This case is a perfect example of how very small tumors of the endocrine system can make a person sick. This picture is enlarged two-fold to make the small round tumor easier to see. In reality, this aldosteronoma was less than one-half inch in diameter. Even when endocrine tumors are benign (most are) they can produce excess hormones which will act on distant organs of the body to make a person sick. Benign adrenal tumors (just like parathyroid tumors) lend themselves very nicely to minimally invasive surgical techniques since the goal of the operation is simply to remove the source of the excess hormone. Laparoscopic surgery for the removal of adrenal tumors was developed in the mid 1990’s and it has quickly been shown to be less stressful on the patient, cause less post-operative pain, require a shorter hospital stay (average 2-3 days instead of 5-7 days), require less pain medicine, and allow a much faster return to regular activities than does the standard open abdominal operation.

Laparoscopic surgery refers to the technique in which a surgeon operates within the abdominal cavity with small telescopes and long instruments. Instead of making a large incision which allows the surgeon access to the abdominal contents where he/she operates with conventional instruments and their hands, a series of small (~ 1/4 to 3/4 inch) incisions are made and specialized instruments are used. One of these instruments instills air into the abdominal cavity to blow it up (like a balloon but only under modest pressure). This instillation of air makes it easier to work since the intestines and other organs will fall away from the tissues which are being examined. A camera is then place into the abdominal cavity which allows the surgeon to see what he/she is doing. The remainder of the small holes (ports) have long instruments (forceps, scissors, etc.) placed through them into the abdomen for the actual dissecting of tissues. The patient on the right is positioned on his side for a laparoscopic adrenalectomy.

This picture depicts a long instrument dissecting the left adrenal vein as it empties into the renal (kidney) vein during the laparoscopic resection of an adrenal tumor. The adrenal tumor is the large orange mass which makes up the right-upper portion of the picture. The left adrenal gland normally lives on top of the kidney (the flesh-colored organ on the right side of the picture), and under the pancreas and spleen. During the dissection of the left adrenal, the pancreas and spleen must be lifted up to allow the surgeon access to the adrenal. Here, the spleen (normally this same purple color) and the pancreas (normally this same yellow color) have been lifted (dissected) off of the adrenal and and kidney are held out of the way with a “fan” retractor in preparation for clipping the adrenal vein. The relationship of the adrenal glands to other organs in the abdomen can be seen nicely on CAT scans and MRI scans which are demonstrated on our page on adrenal X-ray tests.

The picture on the right shows a close-up of the adrenal vein which is smaller than the renal vein and is going to have clips placed on it so it can be cut without bleeding. Once the adrenal artery and vein are identified, clipped, and then cut, the adrenal gland itself is dissected off of the kidney and then removed. Surgeons will put a small cloth bag through a port and into the abdominal cavity. The adrenal tumor is placed into this bag which makes it easier to remove through the relatively small skin incisions and ports.

Who is a Candidate For Laparoscopic Adrenalectomy?

• Tumors less than 10 cm in diameter (~ 4 inches). Tumors larger than this are more likely to be cancerous and therefore require better exposure and a more aggressive operation. Tumors larger than this also pose a technical problem because the surgeon has difficulty seeing around it with the camera.

• Tumors which secrete hormone. These masses are ideally suited for this approach.

• Pheochromocytomas. Pheochromocytomas are tumors which arise from the central zone of the adrenal gland (the medulla) and secrete epinephrine (adrenaline). Since they are usually small and benign, they can be removed with great success using this minimally invasive approach.

• Tumors which do not secrete hormone…if they are greater than 4 cm (~ 1 3/4 inches). Laparoscopic adrenalectomy is the perfect approach to these masses which would otherwise necessitate numerous repeated CAT scans and often life-long follow-up by a physician.

• Tumors which have NO characteristics of malignancy. Laparoscopic removal of the adrenal gland is not appropriate for any cancerous tumors or those which have clinical / radiologic characteristics of malignancy.

Laparoscopic Retroperitoneal Lymph Node Dissection (RPLND) provides patients with a safe and effective way to remove retroperitoneal lymph nodes in patients with testicular cancer. Laparoscopic RPLND is a minimally invasive technique, which provides patients with less discomfort when compared to the traditional open surgery.
Laparoscopic RPLND has resulted in significantly less post-operative pain, a shorter hospital stay, earlier return to work and daily activities, a more favorable cosmetic result and outcomes similar to that of open surgery.
Testicular cancer is one of the success stories in the treatment of malignant tumors. Advances in diagnostic x-rays, radiation, and chemotherapy allow for a cure in the majority of cases. Testicular cancer usually spreads in a predictable manner, going first to the lymph nodes, located behind the major organs in the abdomen.
When testes cancer is detected, removal of the testicle (orchiectomy) is first performed. This gives important information regarding the type of cancer and the risk that it may have spread. Blood work including, AFP (Alpha-fetoprotein), Lactic Dehydrogenase (LDH) and Quantitative HCG (Human Chorionic Gonadotropin) are done along with a chest x-ray and an abdominal CT scan to determine the stage of the disease and the best treatment option. Treatment options (depending on the stage and type of cancer) include

1. Surveillance
2. RPLND
3. Chemotherapy
4. Radiation
What to expect during you preoperative consultation
During your initial consultation with your surgeon, he will review your medical history as well as any outside reports, records, and outside Xray films (e.g. CT scan, MRI, sonogram). A brief physical examination will also be performed at the time of your visit. If your surgeon determines that you are a candidate for surgery, you will then meet with a Patient Service Surgery Coordinator to arrange for the date of your operation.

NOTE: It is very important that you gather and bring all of your Xray films and reports to your initial consultation with your surgeon.

What to expect prior to the surgery

Since insurance companies will not permit patients to be admitted to the hospital the day before surgery to have tests completed, you must make an appointment to have pre-operative testing done at your family doctor or primary care physician’s office within 1 month prior to the date of surgery.

These results need to be faxed by your doctor’s office to the Pre-operative Evaluation Center at 443-287-9358 two weeks prior to your surgery. Please call The Documentation Center at 410-955-9453 two weeks before your surgery date to confirm that this information was received..
Once your surgical date is secured, you will receive a form along with a letter of explanation to take to your primary care physician or family doctor in order to have the following pre-operative testing done prior to your surgery.

• Physical exam

• EKG (electrocardiogram)

• CBC (complete blood count)

• PT / PTT (blood coagulation profile)

• Comprehensive Metabolic Panel (blood chemistry profile)

• (AFP) Alpha-fetoprotein (blood work)

• (HCG) Human Chorionic Gonadotropin (blood work)

• (LDH) Lactic Dehydrogenase

• Urinalysi

• Chest x-ray

• CT scan of the abdomen

Preparation for surgery

Medications to Avoid Prior to Surgery
Aspirin, Motrin, Ibuprofen, Advil, Alka Seltzer, Vitamin E, Ticlid, Coumadin, Lovenox, Celebrex, Voltaren, Vioxx, Plavix and some other arthritis medications can cause bleeding and should be avoided 1 week prior to the date of surgery (Please contact your surgeon’s office if you are unsure about which medications to stop prior to surgery. Do not stop any medication without contacting the prescribing doctor to get their approval).

Bowel Preparation and Clear Liquid Diet

Do not eat or drink anything after midnight the night before the surgery and drink one bottle of Magnesium Citrate (can be purchased at your local pharmacy) the evening before your surgery.
Drink only clear fluids for a 24-hour period prior to the date of your surgery. Clear liquids are liquids that you are able to see through. Please follow the diet below.
Clear Liquid Diet
Remember not to eat or drink anything after midnight the evening before your surgery.

Clear liquids are liquids that you are able to see through. Please follow the diet below.
• Water

• Clear Broths (no cream soups, meat, noodles etc.)

o Chicken broth
o Beef broth

• Juices (no orange juice or tomato juice)

o Apple juice or apple cider
o Grape juice
o Cranberry juice
o Tang
o Hawaiian punch
o Lemonade
o Kool Aid
o Gator Aid

• Tea (you may add sweetener, but no cream or milk)

• Coffee (you may add sweetener, but no cream or milk)

• Clear Jello (without fruit)

• Popsicles (without fruit or cream)

• Italian ices or snowball (no marshmallow)

The Operation

The length of the operation is typically 3-5 hours. The surgery is performed through 3 – 4 small (1 cm) incisions created in the midline of the abdomen. Lymph nodes are removed on the side of the testicular cancer. Using a small telescope and other instrumentation, the lymph tissue that drains the testicle is removed.
The number of lymph nodes to be removed can vary among individuals and can range from less than I 0 to over 50 Lymph nodes are are part of the immune system, which help in fighting off infection.
The relative number of lymph nodes removed during RPLND are not enough to affect your immune system or your body’s ability to fight off infection. Along with the removal of the lymph nodes the remainder of the blood supply to the affected testicle and spermatic cord is also removed.

Potential Risks and Complications

Although this procedure has proven to be very safe, as in any surgical procedure there are risks and potential complications. The safety and complication rates are similar when compared to the open surgery. Potential risks include:
Bleeding: Blood loss during this procedure is possible , however, a blood transfusion is rarely needed. If you are interested in autologous blood transfusion (donating your own blood) you must make your surgeon aware. When the packet of information is mailed to you regarding your surgery, you will receive an authorization form for you to take to the Red Cross in your area.

Infection: All patients are treated with intravenous antibiotics, prior to starting surgery to decrease the chance of infection from occurring after surgery. If you develop any signs or symptoms of infection after the surgery (fever, drainage from your incisions, urinary frequency/discomfort, pain or anything that you may be concerned about) please contact us at once.

Tissue / Organ Injury: Although uncommon, possible injury to surrounding tissue and organs including bowel, vascular structures, spleen, liver, pancreas and gallbladder could require further surgery. Injury could occur to nerves or muscles related to positioning. Hernia at incision site is a possibility. Although very rare, the kidney and ureter on the side that the lymph nodes are being removed could be injured.

Hernia: Hernias at incision sites rarely occur since all keyhole incisions are closed carefully at the completion of your surgery.

Conversion to Open Surgery: The surgical procedure may require conversion to the standard open operation if difficulty is encountered during the laparoscopic procedure. This could result in a larger standard open incision and possibly a longer recuperation period.

Sperm Banking: Patients should consider banking sperm prior to any treatment for their testis cancer, esp. chemotherapy because chemotherapy may effect sperm production by your remaining testicle. The return of sperm quality could take over one year following chemotherapy but may never return to normal levels.

Retrograde Ejaculation/Infertility: Occasionally nerves that control ejaculation may be injured during surgery. This may result in retrograde ejaculation causing sperm to be expelled into the bladder instead of out the tip of the penis. As such, one may not see a discharge (i.e. ejaculate) with orgasm. The fluid will mix in the bladder with urine and be eliminated with the next urination. This condition is not dangerous and does not affect your ability to have erections or an orgasm. This could, however, affect future fertility.

Lymphocele: Lymphatic fluid can collect in the area where the lymph nodes were removed. This could require drainage and further surgery.

Respiratory Complication: If you received a chemotherapy medication called bleomycin before your surgery, you are at a slightly higher risk of lung complications during and following surgery.

Bariatric surgery (weight loss surgery) includes a variety of procedures performed on people who have obesity. Weight loss is achieved by reducing the size of the stomach with a gastric band or through removal of a portion of the stomach (sleeve gastrectomy or biliopancreatic diversion with duodenal switch) or by resecting and re-routing the small intestine to a small stomach pouch (gastric bypass surgery).
Long-term studies show the procedures cause significant long-term loss of weight, recovery from diabetes, improvement in cardiovascular risk factors, and a mortality reduction from 40% to 23%. However, a study in Veterans Affairs (VA) patients has found no survival benefit associated with bariatric surgery among older, severely obese people when compared with usual care, at least out to seven years.
The U.S. National Institutes of Health recommends bariatric surgery for obese people with a body mass index (BMI) of at least 40, and for people with BMI of at least 35 and serious coexisting medical conditions such as diabetes.[1] However, research is emerging that suggests bariatric surgery could be appropriate for those with a BMI of 35 to 40 with no comorbidities or a BMI of 30 to 35 with significant comorbidities. The most recent ASMBS guidelines suggest the position statement on consensus for BMI as an indication for bariatric surgery. The recent guidelines suggest that any patient with a BMI of more than 30 with comorbidities is a candidate for bariatric surgery.

• “Surgery should be considered as a treatment option for patients with a BMI of 40 kg/m2 or greater who instituted but failed an adequate exercise and diet program (with or without adjunctive drug therapy) and who present with obesity-related comorbid conditions, such as hypertension, impaired glucose tolerance, diabetes mellitus, hyperlipidemia, and obstructive sleep apnea. A doctor–patient discussion of surgical options should include the long-term side effects, such as a possible need for reoperation, gallbladder disease, and malabsorption.”

• “Patients should be referred to high-volume centers with surgeons experienced in bariatric surgery.”
In 2011, the International Diabetes Federation issued a position statement suggesting “Under some circumstances, people with a BMI 30–35 should be eligible for surgery.” When determining eligibility for bariatric surgery for extremely obese patients, psychiatric screening is critical; it is also critical for determining postoperative success. Patients with a body-mass index of 40 kg/m2 or greater have a 5-fold risk of depression, and half of bariatric surgery candidates are depressed.

Classification of surgical procedures

Procedures can be grouped in three main categories:[9] Standard of care in the United States and most of the industrialized world in 2009 is for laparoscopic as opposed to open procedures. Future trends are attempting to achieve similar or better results via endoscopic procedures.

Predominantly malabsorptive procedures

In predominantly malabsorptive procedures, although they also reduce stomach size, the effectiveness of these procedures is derived mainly from creating a physiological condition of malabsorption.

Biliopancreatic diversion

This complex operation is termed biliopancreatic diversion (BPD) or the Scopinaro procedure. The original form of this procedure is now rarely performed because of problems with malnourishment. It has been replaced with a modification known as duodenal switch (BPD/DS). Part of the stomach is resected, creating a smaller stomach (however the patient can eat a free diet as there is no restrictive component). The distal part of the small intestine is then connected to the pouch, bypassing the duodenum and jejunum.

In around 2% of patients there is severe malabsorption and nutritional deficiency that requires restoration of the normal absorption. The malabsorptive effect of BPD is so potent that those who undergo the procedure must take vitamin and dietary minerals above and beyond that of the normal population. Without these supplements, there is risk of serious deficiency diseases such as anemia and osteoporosis.
Because gallstones are a common complication of the rapid weight loss following any type of bariatric surgery, some surgeons remove the gallbladder as a preventive measure during BPD. Others prefer to prescribe medications to reduce the risk of post-operative gallstones.[citation needed]

Far fewer surgeons perform BPD compared to other weight loss surgeries, in part because of the need for long-term nutritional follow-up and monitoring of BPD patients.[citation needed]
Jejunoileal bypass

This procedure is no longer performed. It was a surgical weight-loss procedure performed for the relief of morbid obesity from the 1950s through the 1970s in which all but 30 cm (12 in) to 45 cm (18 in) of the small bowel was detached and set to the side.

Endoluminal sleeve

A study on humans was done in Chile using the same technique [10] however the results were not conclusive and the device had issues with migration and slipping. A study recently done in the Netherlands found a decrease of 5.5 BMI points in 3 months with an endoluminal sleeve.

Predominantly restrictive procedures

Procedures that are solely restrictive act to reduce oral intake by limiting gastric volume, produce early satiety, and leave the alimentary canal in continuity, minimizing the risks of metabolic complications. [11]

Adjustable gastric band

The restriction of the stomach also can be created using a silicone band, which can be adjusted by addition or removal of saline through a port placed just under the skin. This operation can be performed laparoscopically, and is commonly referred to as a “lap band”. Weight loss is predominantly due to the restriction of nutrient intake that is created by the small gastric pouch and the narrow outlet. [12] It is considered one of the safest procedures performed today with a mortality rate of 0.05%.

Sleeve gastrectomy

Sleeve gastrectomy, or gastric sleeve, is a surgical weight-loss procedure in which the stomach is reduced to about 15% of its original size, by surgical removal of a large portion of the stomach, following the major curve. The open edges are then attached together (typically with surgical staples, sutures, or both) to leave the stomach shaped more like a tube, or a sleeve, with a banana shape. The procedure permanently reduces the size of the stomach. The procedure is performed laparoscopically and is not reversible.
This combined approach has tremendously decreased the risk of weight loss surgery for specific groups of patients, even when the risk of the two surgeries is added. Most patients can expect to lose 30 to 50% of their excess body weight over a 6–12 month period with the sleeve gastrectomy alone. The timing of the second procedure will vary according to the degree of weight loss, typically 6 – 18 months.

• Stomach volume is reduced, but it tends to function normally so most food items can be consumed in small amounts.
• Removes the portion of the stomach that produces the hormone that stimulates hunger (Ghrelin), although the durability of this removal has yet to be confirmed.[14]
• Dumping syndrome is less likely due to the preservation of the pylorus (although dumping can occur any time stomach surgery takes place).
• Minimizes the chance of an ulcer occurring.
• By avoiding the intestinal bypass, the chance of intestinal obstruction (blockage), anemia, osteoporosis, protein deficiency and vitamin deficiency are significantly reduced.
• Very effective as a first stage procedure for high BMI patients (BMI >55 kg/m2).
• Limited results appear promising as a single stage procedure for low BMI patients (BMI 35–45 kg/m2).
• Appealing option for people with existing anemia, Crohn’s disease, irritable bowel syndrome, and numerous other conditions that make them too high risk for intestinal bypass procedures.

Intragastric balloon (gastric balloon)

Intragastric balloon involves placing a deflated balloon into the stomach, and then filling it to decrease the amount of gastric space. The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5–9 BMI over half a year.[15] The intragastric balloon is approved in Australia, Canada, Mexico, India, United States (received FDA approval in 2015) and several European and South American countries.[16][17] The intragastric balloon may be used prior to another bariatric surgery in order to assist the patient to reach a weight which is suitable for surgery, further it can also be used on several occasions if necessary.

There are three cost categories for the intragastric balloon: pre-operative (e.g. professional fees, lab work and testing), the procedure itself (e.g. surgeon, surgical assistant, anesthesia and hospital fees) and post-operative (e.g. follow-up physician office visits, vitamins and supplements).
Quoted costs for the intragastric balloon are surgeon-specific and vary by region. Average quoted costs by region are as follows (provided in United States Dollars for comparison): Australia: $4,178 USD; Canada: $8,250 USD; Mexico: $5,800 USD; United Kingdom: $6,195 USD; United States: $8,150 USD).[19]
Gastric plication

Basically, the procedure can best be understood as a version of the more popular gastric sleeve or gastrectomy surgery where a sleeve is created by suturing rather than removing stomach tissue thus preserving its natural nutrient absorption capabilities. Gastric plication significantly reduces the volume of the patient’s stomach, so smaller amounts of food provide a feeling of satiety.[20] The procedure is producing some significant results that were published in a recent study in Bariatric Times and are based on post-operative outcomes for 66 patients (44 female) who had the gastric sleeve plication procedure between January 2007 and March 2010. Mean patient age was 34, with a mean BMI of 35. Follow-up visits for the assessment of safety and weight loss were scheduled at regular intervals in the postoperative period. No major complications were reported among the 66 patients. Weight loss outcomes are comparable to gastric bypass.
The study describes gastric sleeve plication (also referred to as gastric imbrication or laparoscopic greater curvature plication) as a restrictive technique that eliminates the complications associated with adjustable gastric banding and vertical sleeve gastrectomy—it does this by creating restriction without the use of implants and without gastric resection (cutting) and staples.

Mixed procedures apply both techniques simultaneously.

Gastric bypass surgery

A common form of gastric bypass surgery is the Roux-en-Y gastric bypass, designed to reduce the amount of food a person is able to eat by cutting away a part of the stomach, gastric bypass is a permanent procedure that helps patients by changing how the stomach and small intestine handle the food that is eaten to achieve and maintain weight loss goals.[21] After the surgery, the stomach will be smaller. A patient will feel full with less food.
The gastric bypass had been the most commonly performed operation for weight loss in the United States, and approximately 140,000 gastric bypass procedures were performed in 2005. Its market share has decreased since then and by 2011, the frequency of gastric bypass was thought to be less than 50% of the weight loss surgery market.
A factor in the success of any bariatric surgery is strict post-surgical adherence to a healthy pattern of eating.
There are certain patients who cannot tolerate the malabsorption and dumping syndrome associated with gastric bypass. In such patients, although earlier considered to be an irreversible procedure, there are instances where gastric bypass procedure can be partially reversed.

Sleeve gastrectomy with duodenal switch

A variation of the biliopancreatic diversion includes a duodenal switch. The part of the stomach along its greater curve is resected. The stomach is “tubulized” with a residual volume of about 150 ml. This volume reduction provides the food intake restriction component of this operation. This type of gastric resection is anatomically and functionally irreversible. The stomach is then disconnected from the duodenum and connected to the distal part of the small intestine. The duodenum and the upper part of the small intestine are reattached to the rest at about 75–100 cm from the colon.[citation needed]

Implantable gastric stimulation

This procedure where a device similar to a heart pacemaker is implanted by a surgeon, with the electrical leads stimulating the external surface of the stomach, is being studied in the USA. Electrical stimulation is thought to modify the activity of the enteric nervous system of the stomach, which is interpreted by the brain to give a sense of satiety, or fullness. Early evidence suggests that it is less effective than other forms of bariatric surgery.[22]

Eating after bariatric surgery

Immediately after bariatric surgery, the patient is restricted to a clear liquid diet, which includes foods such as clear broth, diluted fruit juices or sugar-free drinks and gelatin desserts. This diet is continued until the gastrointestinal tract has recovered somewhat from the surgery. The next stage provides a blended or pureed sugar-free diet for at least two weeks. This may consist of high protein, liquid or soft foods such as protein shakes, soft meats, and dairy products. Foods high in carbohydrates are usually avoided when possible during the initial weight loss period.
Post-surgery, overeating is curbed because exceeding the capacity of the stomach causes nausea and vomiting. Diet restrictions after recovery from surgery depend in part on the type of surgery. Many patients will need to take a daily multivitamin pill for life to compensate for reduced absorption of essential nutrients.[23] Because patients cannot eat a large quantity of food, physicians typically recommend a diet that is relatively high in protein and low in fats and alcohol.

Fluid recommendations

It is very common, within the first month post-surgery, for a patient to undergo volume depletion and dehydration. Patients have difficulty drinking the appropriate amount of fluids as they adapt to their new gastric volume. Limitations on oral fluid intake, reduced calorie intake, and a higher incidence of vomiting and diarrhea are all factors that have a significant contribution to dehydration. In order to prevent fluid volume depletion and dehydration, a minimum of 48–64 fl oz (1.4-1.9 L) should be consumed by repetitive small sips all day.

Effectiveness of surgery
Weight loss
In general, the malabsorptive procedures lead to more weight loss than the restrictive procedures; however, they have a higher risk profile. A meta-analysis from University of California, Los Angeles, reports the following weight loss at 36 months:[5]
• Biliopancreatic diversion — 117 Lbs / 53 kg
• Roux-en-Y gastric bypass (RYGB) — 90 Lbs / 41 kg
• Open — 95 Lbs/ 43 kg
• Laparoscopic — 84 Lbs / 38 kg
• Vertical banded gastroplasty — 71 Lbs / 32 kg
The maximum weight loss occurs in the first 10 months after surgery. More recent studies have demonstrated that the medium (3–8 years) and long term (> 10 years) weight loss results for RYGB and LAGB become very similar.[25] However, the range of excess weight loss for LAGB patients (25% to 80%) is much broader than that of RYGB patients (50% to 70%). Data (beyond 5 years) for sleeve gastrectomy indicates weight loss statistics similar to RYGB.
Reduced mortality and morbidity
In the short term, weight loss from bariatric surgeries is associated with reductions in some comorbidities of obesity, such as diabetes, metabolic syndrome and sleep apnea, but the benefit for hypertension is uncertain. It is uncertain whether any given bariatric procedure is more effective than another in controlling comorbidities. There is no high quality evidence concerning longer-term effects compared with conventional treatment on comorbidities.[26]
Bariatric surgery in older patients has also been a topic of debate, centered on concerns for safety in this population; the relative benefits and risks in this population is not known.[26]
Given the remarkable rate of diabetes remission with bariatric surgery, there is considerable interest in offering this intervention to people with type 2 diabetes who have a lower BMI than is generally required for bariatric surgery, but high quality evidence is lacking and optimal timing of the procedure is uncertain.
Laparoscopic bariatric surgery requires a hospital stay of only one or two days. Short-term complications from laparoscopic adjustable gastric banding are reported to be lower than laparoscopic Roux-en-Y surgery, and complications from laparoscopic Roux-en-Y surgery are lower than conventional (open) Roux-en-Y surgery